Welcome to KarenGraceKassy.com

Offline Consultation Signup (If you are unable to print this page, contact our office via email. We'll send you a copy via regular mail)

-Please do not provide any other information besides name and age.
-Remember, consultations are not appropriate for emergency purposes.
-You can only fill out this form for yourself, not another person.

Dear Client and Animal Caretaker,
Thank you for your inquiry. Below, please
 Sign & date. Fill out the form completely, or I cannot do the reading.
 Two forms of payment are accepted: check, money ordered, or credit card
 Return this form to me with either a check made out to Karen Kassy for $90 (US FUNDS).
 OR pay by credit card:
Name on Credit Card: __________________________________
Visa/Mastercard number: _ _ _ _ -_ _ _ _ - _ _ _ _ - _ _ _ _ expiration: ___/___

Signature: _____________________________
 As soon as I receive this, I’ll call you to set up an appointment. You must give at least 24 hours notice to change your appointment once it has been set.
 Please return to: Karen Kassy: PO Box 8043: Bend, OR 97708-8043
 NOTE: Do NOT send registered mail, certified mail, return signature required, etc., as this will only delay response time.
 DAYTIME phone number to reach you: _____________________________
 EVENING phone number to reach you: ______________________________
 EMAIL ADDRESS to reach you: ___________________________________
 I like to thank the people who send me clients. If you know who referred you, and how I can get in touch with them, I’d appreciate knowing:
_____________________________________

I ____________________________________ __________ realize that the information
(Print your name) (and your age)

discussed about my animals: _______________ _____ ____ ______
print animals’ name sex age type: (i.e., horse, cat, dog)

with Rev. Karen Grace Kassy is spiritual in nature and is to be used for information purposes only. It should not and will not be used as a substitute for a physician’s or psychiatrist’s medical diagnosis, treatment and care. I realize any action I take is of my own, free will and I will assume all risks associated with the use of his information. I agree that I will not hold Karen Grace Kassy, in any case, liable, at any time, for any direct, indirect, special, incidental, consequential or punitive damages. I understand that there are no warranties made as to the information’s completeness, accuracy, currency or reliability as relates to this health reading and any discussion thereof.

I also realize that for legal purposes, I acknowledge that I do have a healthcare practitioner with whom I will consult if I decide to take action or change anything regarding my healthcare.

________________________________ ___________
Signature Date